Definition of a Payer
Gail Kocher, WEDI HPID Workgroup Co-Chair
Laurie Burckhardt, WEDI HPID Implementation SWG Co-Chair
Agenda
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Issue Brief Overview
White Paper
– Development will be led by the HPID Implementation SWG
– Interactive discussion to kick-off development
Issue Brief Overview
Health Plan and Payer are Different
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Industry has tended to use the terms synonymously
Regulation defines “health plan” differently than the way the industry
commonly uses the term
Variation in terminology usage has created additional interpretation issues
Issue Brief Overview
Health Plan
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The HPID Final Rule relies on the definition of “health plan” under HIPAA in
45 CFR §160.103:
“Health plan means an individual or group plan that provides, or pays the
cost of, medical care (as defined in section 2791(a)(2) of the PHS Act, 42
U.S.C. 300gg–91(a)(2)).”
The Code of Federal Regulations further defines what types of plans are
included in a “health plan”.
Issue Brief Overview
Payer
The term ”payer” as used in the transactions is defined as the intended entity
that is responsible for one or more of the following:
– final processing of the claim in order to return the remittance advice.
– final processing of the inquiry (eligibility, services review or claim status)
in order to return the response (eligibility, services review or claim
status).
– final processing of the (member) enrollment or premium payment.
Note: This definition excludes any business associate used to create or receive
a transaction on behalf of a payer, e.g. a clearinghouse processing eligibility
inquiries and response on behalf of a payer Information Source.
Examples of the value of a payer ID include, but are not limited to NAIC code,
EIN, etc.
Issue Brief Overview
Usage
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The role of payer is distinct from the role of a health plan. Even though an
entity can be in both roles, not all payers are health plans and not all health
plans are payers.
Usage in transactions relies on the identification of the role the entity being
identified is playing. While a health plan can be a payer, in the transactions,
the entity is being identified for its role as a payer not as a health plan.
Payer
– Current use of the payer identification data elements in the ASC X12
transactions is to identify the entity in the role of a payer.
Health Plan
– In instances when a health plan chooses to identify itself as a health
plan in a transaction, the HPID of the health plan is the identifier that
would be used after the HPID Final Rule compliance date.
White Paper
Usage
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Payer
– Additional examples that need to be considered?
Health Plan
– Determine if there are other examples in which a Health Plan is
identified in a transaction
– Currently only 834 is reflected – only example authors could identify
where a health plan would need identified as a health plan
White Paper
HPID is Obtained and Not Used in Transactions
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Communicate HPID strategy to trading partners
− Even if no change
− Results in less calls into your call centers
Need to consider any outbound transactions to other payers
White Paper
Considerations
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837 Claim Transactions
− Need to accommodate Type 1 Errata
• Results in new version control identifier in GS segment
• Potential changes to EDI front-ends, validators, translators
− Require trading partners to test?
− Allow both versions?
− 837 outbound
− Is receiver of data expecting an HPID?
Other
– Additional Use Cases
– Communications between trading partners
– Communication materials specific to self-insured health plans